MASSAGE THERAPIST LICENSE APPLICATION CITY CODE CHAPTER 115. INITIAL INVESTIGATION FEE $25.00 ANNUAL LICENSE FEE $50.00 (includes annual renewal)

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1 MASSAGE THERAPIST LICENSE APPLICATION CITY CODE CHAPTER 115 INITIAL INVESTIGATION FEE $25.00 ANNUAL LICENSE FEE $50.00 (includes annual renewal) NEW RENEW YEAR NAME OF APPLICANT APPLICANT ADDRESS TELEPHONE # ADDRESS NAME OF MASSAGE BUSINESS ADDRESS OF MASSAGE BUSINESS HOURS/DAYS OF OPERATION The applicant shall provide the following information: A. Evidence of age: You must be eighteen (18) years of age or older to apply for a Massage Therapist License B. Evidence of applicant's education including continuing education if applicable. You do not need to resubmit transcripts from previous licensing (renewals) with the City. You should submit new education transcripts or certificates for relevant training. A minimum of 600 hours of certified therapeutic massage training recognized by a state or national organization is part of the licensing requirements. C. Evidence of applicant's character by providing character references School attended and degree received: State the hours of certified therapeutic massage training you have received and include copies for verification. List two (2) character references: Name, Address, and Phone Number. Massage Therapist Application Page Lake Street South Forest Lake MN

2 Has applicant ever been convicted of a crime, other than a traffic violation? YES NO If yes, please give an explanation on a separate piece of paper, including time, place, and nature of such crime or offense and disposition thereof. A renewal license will be required each calendar year. Applicant must complete the application, in full, as required by the City including the renewal fee. Applicants must strictly comply with all regulations promulgated by the City Council of Forest Lake and all ordinances of said municipality and the State of Minnesota. I hereby certify that I have read the foregoing questions and that the answers to said questions are true to the best of my knowledge. I further understand that an investigation for a new license maybe charged by the City. If convicted of any crime other than a traffic offense, I will report such conviction to the City of Forest Lake immediately. I have read and understand the state laws regulating complimentary and alternative health care practices of which massage therapy is currently included. NEW APPLICANTS MUST ALSO COMPLETE AN AUTHORIZATION FOR CONSENT TO RELEASE INFORMATION. Tax Information must be included. If you do not have a business please provide your social security number:. STATE TAX ID # FEDERAL TAX ID # Note that your social security number and tax identification numbers will be kept confidential unless requested by the Internal Revenue Department. SIGNATURE OF APPLICANT AND DATE SIGNED SIGNATURE OF POLICE DEPT. AND DATE OF APPROVAL CITY COUNCIL AND DATE OF APPROVAL Massage Therapist Application Page 2

3 Minnesota Government Data Practices Act Chapter 13 Tennessen Warning Data is requested from the applicant on various forms. The purpose and intended use of the requested data is to verify the applicant meets all state statute and city code provisions and, if the license or permit is approved, to verify that all required data remains current. The following data collected, created, or maintained is classified under the Minnesota Government Data Practices Act as Private data until license approval when the data becomes Public: (13.41, Subd. 4). 1. Data submitted by applicants (other than names and designated addresses). 2. Orders for hearing and findings of fact. 3. Conclusions of law and specification of the final disciplinary action contained in the record of the disciplinary action. 4. Entire record concerning the disciplinary proceeding. 5. License numbers. 6. License status. The following data collected, created, or maintained is classified as Private: (13.41, Subd. 2). 1. The identity of complainants who have made reports concerning licenses or applicants which appear in inactive complaint data unless the complainant consents to the disclosure. 2. The nature or content of unsubstantiated complaints when the information is not maintained in anticipation of legal action. 3. Inactive investigative data relating to violations of statutes or rules. 4. The record of any disciplinary proceeding except as limited by Subd. 4. The following data collected, created, or maintained is classified as Confidential: (13.41, Subd. 3). 1. Active investigative data relating to the investigation of complaints against any license. Under law, private data may be shared with licensing and inspection employees, approval authorities, insurance providers, law enforcement employees, contracted inspection officials, as required by court order and City officials who have a bona fide need for it. The City of Forest Lake may make any data classified as private or confidential accessible to an appropriate person or agency if the licensing agency determines that failure to make the data accessible is likely to create a clear and present danger to public health or safety. We ask that you complete or provide all data requested on the application form(s) unless we have noted that it is not required. Refusal to supply required information may mean that your application cannot be processed. I READ AND UNDERSTAND THE ABOVE INFORMATION REGARDING MY RIGHTS AS A SUBJECT OF GOVERNMENT DATA. Date Signature of Applicant 1408 Lake Street South Forest Lake MN

4 AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION FOR CITY OF FOREST LAKE BACKGROUND CHECK $25.00 FEE YOU MUST ATTACH A COPY OF YOUR DRIVERS LICENSE. License you are applying for: Full Name: First Middle Last Home Address: House # Street City State & Zip Home Phone Number: Include Area Code If applicable, complete the following: Business Name Business Address: Building # Street City State & Zip Business Phone Number: Include Area Code Date of Birth: Drivers License Number (copy of DL attached): I understand that the above-mentioned information about me may be protected under state and /or federal privacy laws or city policy and may not be disclosed without my prior written consent unless otherwise required by law. I also release the City of Forest Lake from any and all liability for its receipt and use of information and records received pursuant to this consent. I further acknowledge that I have carefully read this release, fully understand its terms and legal significance, and execute it voluntarily. Signature of Individual Authorizing Release Date Police Department Approval Signature Date 1408 Lake Street South Forest Lake MN

5 Forest Lake, MN Code of Ordinances MASSAGE THERAPY LICENSE REQUIRED. No person shall perform massage services within the city without obtaining a massage therapist license as provided in this chapter CONTENTS OF APPLICATION FOR A MASSAGE THERAPIST LICENSE. An application for a massage therapist license shall be made only on forms provided by the city. The application shall contain the following information together with any other information the city may require: (A) Evidence of the applicant's educational qualifications, including original or certified copies of degrees, diplomas or certificates, if any, including proof of receiving at least 600 hours of certified therapeutic massage training recognized and accepted by the State of Minnesota or a national professional therapeutic massage organization. (B) Evidence of applicant's practical qualifications to practice massage. (C) Whether the applicant has ever been convicted of a crime or offense other than a traffic offense and, if so, information as to the time, place and nature of such crime or offense MASSAGE THERAPIST LICENSE FEES. The annual new massage therapy license fee shall be in an amount established from time to time by city ordinance. The license year shall be the calendar year and a license shall be valid for the remainder of the calendar year in which it is issued and shall not be prorated. The investigation fee and first annual license fee for the issuance of a license shall be paid when the application is filed. In the event that the application is denied or that the license, once issued, is revoked, canceled or surrendered, no part of the annual license and investigation fee for the issuance of said license shall be returned to the applicant unless by express action of the City Council. A license shall be obtained each calendar year. The annual renewal fee shall be in an amount established from time to time by city ordinance, and shall be accompanied by a completed application. The license holder shall display the license in a prominent place in the licensed location at all times. A license permitting the holder thereof to practice massage therapy is nontransferable INVESTIGATION OF MASSAGE THERAPY LICENSE APPLICATION. Massage therapy license applications shall be reviewed by the Police Department, which shall furnish written recommendations to the City Clerk. Thereafter, licenses shall be granted or denied by the City Clerk subject to the provisions of this chapter. The applicant may appeal to the City Council from the Clerk's decision CONDITIONS GOVERNING ISSUANCE OF A MASSAGE THERAPIST LICENSE. (A) The license shall be issued only to persons who have received and can furnish proof of receiving at least 600 hours of certified therapeutic massage training recognized and accepted by the State of Minnesota or a national professional therapeutic massage organization. (B) The license shall be issued only to persons of good moral character and repute. (C) The license shall be issued only to persons free of convictions for offenses which involve moral turpitude or which relate directly to such person's ability, capacity, or fitness to perform the duties and discharge the responsibilities of the occupation.

6 (D) The license shall not be issued to persons who have, within 1 year prior to the date of application, been denied licensure; or who have had his or her license revoked or surrendered in or by any political subdivision, municipality or by the State of Minnesota. (E) The license shall be issued only to applicants who have fully and truthfully answered all of the information requested in the application and have paid the full license and investigation fee. (F) The license shall be issued only to persons 18 years of age or older RESTRICTIONS AND REGULATIONS. (A) No massage business location licensee shall employ any person as a massage therapist without first insuring that said employee possesses a valid license for the administration or practice of massage in the City of Forest Lake. The license shall be prominently and openly displayed on the premises. (B) The licensed location shall not be open or in operation between the hours of 10:00 p.m. and 8:00 a.m. on the succeeding day nor shall any person engaged in the practice of massage be on said premises or perform any massage or administer any such services between the hours of 10:00 p.m. and 8:00 a.m. on the succeeding day. (C) The licensee, massage therapist and any persons in their employ or agents or officers thereof and any and all persons with interest in said business shall comply with all applicable ordinances, regulations and laws of the City of Forest Lake, the State of Minnesota and the United States of America. (D) If the licensee is a partnership or corporation, the licensee shall designate a person to be manager and in responsible charge of the business. Such person shall remain responsible for conduct of the business until the licensee has designated another suitable person in writing. The licensee shall promptly notify the City of Forest Lake in writing of any change in manager indicating the name, address, date of birth and home telephone number of the new manager and the effective date of such change. (E) Every licensee shall permit and allow an examination and inspection of every part of the premises by a police, fire or other authority of the city during normal business hours. Refusal to allow such inspection or to answer the request of city police, fire, or other authority to be admitted to a licensed premises shall be grounds for suspension or revocation of all licenses. (F) Any person acting as a massage therapist shall have his or her license displayed in a prominent place at his or her place of employment and, upon demand by any police officer or other authorized officer or agent of the city of Forest Lake, any person engaged in practicing massage shall identify himself or herself giving his or her true legal name, correct address, date of birth and home telephone number. (G) No person under 18 years of age shall serve in or be employed in any location licensed under the provisions of this chapter except in a clerical, receptionist or other non-massage capacity. (H) Any person practicing massage therapy within the City of Forest Lake shall initially advise the city of his or her full legal name, address, date of birth, home telephone number and shall advise the city of any changes in address or telephone number within 30 days of such change. (I) Any person practicing massage within the city may do so only at business locations which are licensed for the conduct of such business as herein provided and further, any person practicing massage shall inform the city of any changes in employment or the location of his or her employment within the city within 7 days after such change. (J) Every person to whom a massage therapy license is issued shall provide and allow copying of the person's photograph for identification purposes. (K) Price rates for all services shall be prominently posted in the reception area in a location available to all prospective customers. (Ord. 584, passed ; Am. Ord. 586, passed ) REVOCATION, SUSPENSION OR NON-RENEWAL OF MASSAGE BUSINESS LOCATION LICENSE OR MASSAGE THERAPY LICENSE. A massage business location license or massage therapy license may be revoked, suspended or not renewed by the City Council

7 upon recommendation of the City Clerk by showing that the licensee, its owners, managers, employees, agents or any other interested parties, as enumerated in with the exception of creditors, or the massage therapist have engaged in any of the following conduct: (A) Fraud, deception or misrepresentation in connection with the securing of the licenses. (B) Intemperance in the use of alcohol and or drugs including but not limited to the use of drugs defined in M.S , as it may be amended from time to time, barbiturates, hallucinogenic drugs, amphetamines, benezedrine, dexedrine or other sedatives, depressants, stimulants or tranquilizers. (C) Engaging in conduct involving moral turpitude by permitting or allowing others within their employment or agency to engage in conduct involving moral turpitude or failing to prevent agents, officers or employees in engaging in conduct involving moral turpitude. (D) Failure to fully comply with any requirements of the City Code of the City of Forest Lake regarding sanitary and safety conditions, zoning requirements, Building Code requirements or other ordinances, the violation of which involves moral turpitude, or failure to comply fully with any of the requirements of this chapter. (E) Conviction of an offense involving moral turpitude by any court of competent jurisdiction. (F) Engaging in any conduct, which would constitute grounds for refusal to issue a business location license or massage therapy license herein PENALTY. Whoever does any act forbidden by this chapter or omits or fails to do any act required by this chapter shall be guilty of a misdemeanor.